Drug benefit to give seniors savings and challenges

Starting tomorrow, about 1 million Massachusetts senior citizens will be able to enroll in a program that, for most, will result in substantial savings on prescription drugs.

The federal drug benefit that takes effect in January is the most significant change to the Medicare system since it was created in 1965. Nationwide, about 40 million Americans are eligible to participate; about 30 million expected to enroll. The Congressional Budget Office estimates that seniors can reduce their prescription drug costs next year to an average of $792, about 37 percent less than the current per-person-spending average of $1,257.

But there are pitfalls. Participants have to choose coverage from scores of options, which is a complex and time-consuming process. People who fail to sign up before May 15 may pay a penalty if they enroll later.

Along with insurers familiar to Massachusetts residents -- such as Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim HealthCare, and Tufts Health Plan -- the drug benefit is being marketed by pharmacy benefit companies and out-of-state insurers. In all, 17 companies are offering stand-alone drug plans, some with multiple options, and seven are also offering drug coverage as part of Medicare Advantage plans, which offer more comprehensive coverage.

Even some healthcare professionals are confused by the complexities. Barbra G. Rabson, executive director of the Massachusetts Health Quality Partners, a nonprofit devoted to improving healthcare in the state, spends her days studying managed care, evidence-based medicine, and clinical quality. But she is stumped by the Medicare drug plan.

''I can't even approach it, I'm so confused," Rabson said. ''It's mind-boggling to me -- and I'm supposed to know this stuff."

Rabson said she is trying to determine which of the many options being offered are best for her mother and father, who are retired and live in Maryland.

Other healthcare advocates, seniors, and social workers agree that the plan, known as Medicare Part D, is unwieldy. Even the pharmaceutical industry, which stands to gain from about $72 billion in federal spending on drug coverage annually over the next 10 years, acknowledges that the details are too dense for most people to comprehend. The industry, through a nonprofit operation, has launched public information campaigns in each state to try to demystify the process of choosing a drug plan.

Some politicians and health advocates say the scramble to explain how the benefit works is a symptom of larger problems.

''This is the ultimate example of public policy gone awry," said state Senator Mark C. Montigny, Democrat of New Bedford, coauthor of a 1996 Massachusetts law that expanded drug benefits for some residents. ''In every state of the country, there's such confusion that we'll be lucky if there isn't a national implosion. Seniors are more scared and more confused than if there was no plan."

The program will give seniors a federally mandated drug benefit for the first time. Enrollment for 2006 will continue until May 15.

Critics say the program's design is flawed. The federal government created a standard plan that pays for drugs after a $250 deductible. But for annual expenses between $2,250 and $5,100, there is no coverage -- a gap commonly referred to as the ''doughnut hole."

Coverage to fill that gap is provided by private companies, which have fashioned their own plans, based on the government template. In addition, most plans require several levels of copayments depending on how the drugs are categorized.

The result is a labyrinth of rules, exclusions, fees, penalties, exceptions, and geographical anomalies that would challenge a chess grand master. The concern it has generated was evident recently in the office of Nancy Roper, a volunteer at Action for Boston Community Development, an antipoverty agency. Roper is charged with helping low-income seniors navigate the specifics of the new drug program.

''I went to a training meeting and I'm confused," she said. ''I'm an intelligent person, but I don't understand what's going on here."

She said an avalanche of mailings from the government intended to explain the program to seniors is only making them apprehensive. ''Whenever the government starts knocking on their door, their antennae go up, and they get real nervous," said Roper. ''They think the government is going to take something away. And that's why they end up throwing the mail away."

Last month, seniors started receiving the government's annual handbook, ''Medicare & You," which contains a guide to the drug plan. But some find the 98-page pamphlet intimidating.''There's too much there to absorb," said Marjorie Keefe, 80, of Dorchester. ''It should be shorter. You wonder if they're really trying to help you."

Medicare is offering other tools to help seniors and their family members choose a drug plan. But some of the tactics have come under attack. Families USA, a nonprofit group for healthcare consumers, recently called Medicare's Plan Finder web tool ''a mess." ''Even if the confusing and complicated tool worked as planned, such a multistep, Web-based instrument is ill-suited to serve the Medicare population," said Ron Pollack, executive director, in a statement. The system, he said, ''is leaving most seniors bewildered."

The Kaiser Family Foundation, a nonprofit, nonpartisan organization that studies healthcare issues, found that many of the roughly 30 million people eligible for the new program will benefit. Those paying full premiums will save an average of 28 percent on out-of-pocket expenses for drugs. About 8.7 million people who qualify for low-income assistance will save more -- an average of 83 percent.

Roper is helping clients determine if they qualify for the low-income subsidies -- a process that can take 10 minutes on the phone. But the even bigger challenge is trying to select one of the dozens of plans being offered in Massachusetts. Choosing involves a laborious process of comparing benefits, premiums, and copayments, and reading a lot of fine print.

''Choice is a wonderful thing until it paralyzes you," said Cindy Parks Thomas, a senior scientist at the Heller School at Brandeis University in Waltham.

James Ambrose, 86, of Bedford, said he is not intimidated by the program. He sat through an hour-long presentation by Tufts Health Plan on the program at the Old Country Buffet in the Watertown Mall. ''I found it very informative," said Ambrose, a retired tool and die maker. ''I write everything down, so we can compare apples with apples." His first step will be to call his insurance company to find out how the Medicare drug benefit compares with his current health and prescription insurance. ''At our age," he said, ''we don't make hasty decisions."

Jeffrey Krasner can be reached at krasner@globe.com.